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New Facility Existing Facility San Joaquin County Environmental Health Department Facility Name State cCi APN Repairs or Remodel Other Consultation Change of Owner License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect ft Billing Party OQ, Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Address ZIP Contractor Billing Party Facility Owner Facility Contact First Name Last name City State ZIPAddress EmailPhonePhone Property Owner Contractor Billing Party Facility Owner Facility Contact If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress Phone EmailPhone DATE: OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Linked FA IDAccepted By Rev 06/12/2024 Contact Types required If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative._______________________________________________ SI Application for Operating Permit Phone Fee Record Number ftp 24^ ii4& Type of Service Requested Comments Phone fOexO PUort If mobile food truck or pumper truck Co pc 7 CltYSVoc^o Application Form Site Address 3?1Z Pogolo 'Supervisor District K Ov'e n ZIP -t— Last name Cu_____ Email Cf €r k 30 Assigned To , n /-xV- iSlocUo. Date ICD\W\2-H State ;u TteVC C #6-/4. C o Architect if contractor, indicate type and BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this apolication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ,f/ -r~ / 7~ Al' ! ! I I 14 APPLICANT'S SIGNATURE:DATE: ' ' OTHER AUTHORIZED AGENT Property Owner